Allergic Rhinitis vs. a Cold, Flu or RSV - What the Allergy Visit Note Should Document (Pertinent Negatives and ICD-10)

The short answer: when a patient asks "allergies or a virus?", the

note should show how the clinician got to the answer. That means four

things. The onset and time course: sudden or gradual, how many days,

and whether last fall looked the same. The pertinent negatives: no

fever, no body aches, no chills, no sick contacts, if that's what the

patient said. The pertinent positives: itching, sneezing, a thin or

colored discharge, symptoms that change with the setting. And an

assessment worded to match the certainty, because outpatient coding

follows the words the clinician uses.

Fall is when the question gets harder, because the respiratory virus

season overlaps with fall allergy symptoms. CDC's clinical

overview, as of this writing, says "In most regions of the United

States, RSV season starts in the fall and peaks in the winter." The patient sure they have "a cold that won't

quit" and the patient with early flu can sit in the same waiting room.

The note is where the difference gets written down.

This is a documentation guide, not a diagnostic protocol. The clinician

makes the call. The sources are listed at the end and linked where they

are used.

What the sources say separates them

These are the differences that the public guidance from CDC, AAAAI and

ACAAI uses. Each one becomes a line in the history.

Fever. ACAAI's patient page on hay fever says that hay fever "does

not cause a fever." For a cold, it says the patient "may have a thicker or yellowish

discharge from your nose and may have a low-grade fever"

(ACAAI).

CDC's cold-versus-flu comparison lists fever as rare with a cold and

common with flu, lasting 3 to 4 days. CDC also notes that "not everyone

with flu will have a fever"

(CDC flu symptoms).

So "afebrile" is useful, but on its own it doesn't settle the question.

Onset. CDC says "Flu symptoms usually come on suddenly," and its

table lists cold onset as gradual and flu onset as abrupt. ACAAI says

hay fever symptoms "can begin immediately after you are exposed to

allergens," while a cold "will most likely begin a day or two after

exposure to the virus." For RSV, CDC says people "usually show symptoms

within 4 to 6 days after getting infected" and that "These symptoms

usually appear in stages and not all at once"

(CDC RSV symptoms).

Aches, chills and fatigue. In CDC's table, aches are slight with a

cold and "common; often severe" with flu. Chills are uncommon with a

cold and fairly common with flu. Fatigue is sometimes present with a

cold and usual with flu. AAAAI lists body aches under colds and not

under allergies

(AAAAI).

Itching. AAAAI lists an "itchy nose; watery or itchy eyes" under

allergies, not under colds.

Duration and pattern. AAAAI says a cold should clear up within

several days, while allergy symptoms last "as long as exposure." Its

rule of thumb is that symptoms lasting more than a week, or that "seem

to turn off and on based on your surroundings," point toward allergies

or sinusitis. ACAAI says a cold "can last a few days to a week," while

hay fever symptoms continue "as long as your exposure continues."

Overlap. None of these is clean. CDC lists sneezing and a runny or

stuffy nose as common with colds and present sometimes with flu. Its

RSV list includes runny nose, congestion, sneezing and cough. CDC also

says "Adults who get RSV usually have mild or no symptoms," and that

their symptoms "are usually consistent with an upper respiratory tract

infection"

(CDC RSV clinical overview).

That overlap is why the note has to show the pattern, not just a list of

nasal symptoms.

Template 1: onset, course and exposure pattern

```

ONSET AND COURSE

• Onset: [sudden / gradual]; date: [ ]; days so far: [ ]
• Course: [steady / worsening / improving / improved then worse]
• Same time last year: [yes / no / unsure]
• Prior seasons with the same pattern: [ ]

EXPOSURE PATTERN

• Better indoors / outdoors / away from home: [ ]
• Worse with: [outdoor time / yard work / pets / dust / damp

basement / heating turned on / none noted]

• Sick contacts at home, school or work: [yes / no / unknown]
• Travel: [ ]

```

AAFP's 2023 rapid evidence review says "Diagnosis of allergic rhinitis

is based on patient history, physical examination, and at least one of

the following symptoms": "nasal congestion, runny or itchy nose, or

sneezing." It adds that "History

should include whether the symptoms are seasonal or perennial, symptom

triggers, and severity"

(AAFP).

The "same time last year" and "sick contacts" lines are the quickest

way to give the next reader that context.

Template 2: pertinent positives and negatives

```

REVIEW OF SYSTEMS (as reported today)

• Fever: [none / subjective / measured: Tmax ___]
• Chills: [no / yes]
• Body or muscle aches: [none / mild / severe]
• Fatigue: [none / mild / marked]
• Headache: [no / yes]
• Sore throat: [no / yes]
• Cough: [none / dry / productive]; wheeze: [no / yes]
• Nasal discharge: [thin and watery / thick / colored]
• Sneezing: [no / yes]
• Itchy nose: [no / yes]; itchy or watery eyes: [no / yes]
• Sinus pressure or facial pain: [no / yes]
• Vomiting or diarrhea: [no / yes]
• Shortness of breath: [no / yes]

```

The negatives are the part most often dropped. "Rhinorrhea and

congestion" without "no fever, no myalgias, no sick contacts" reads the

same whether the assessment was allergic rhinitis or a viral infection.

Write down what the patient denied as well as what they reported. It is

the record of why the clinician leaned one way.

Two lines are worth keeping for specific patients. CDC lists vomiting

and diarrhea with flu, "more common in children than adults." And for

patients with asthma, CDC says "People with asthma are at higher risk

of developing serious flu complications, even if their asthma is mild,"

and "Flu can trigger asthma attacks and cause worsening of asthma

symptoms"

(CDC flu and asthma).

When an asthma patient shows up with "allergies," the cough, wheeze and

breathing lines tie this visit to the

asthma follow-up note.

Template 3: exam and testing

```

EXAM

• Temperature today: [ ]
• Nasal mucosa: [pale / boggy / erythematous / normal]
• Turbinates: [ ]
• Discharge: [clear / purulent / none]
• Eyes: [conjunctival injection / tearing / allergic shiners / normal]
• Pharynx: [ ]
• Lungs: [clear / wheeze / other]

TESTING

• Viral testing: [not done / flu / RSV / other: result]
• Allergy testing: [not done / prior results reviewed / ordered]

```

AAFP lists "clear rhinorrhea, pale nasal mucosa, swollen nasal

turbinates" as common findings, along with watery eye discharge,

conjunctival swelling and allergic shiners. It also cautions that

"Physical examination findings are often nonspecific." Record what was

seen and let the assessment carry the clinician's reasoning.

If prior skin-test results exist, write which ones bear on this season,

for example a ragweed sensitization. The

skin test documentation checklist

covers how those results get recorded in the first place.

Template 4: the assessment, worded to match the certainty

```

ASSESSMENT

• [Allergic rhinitis, seasonal, pollen / allergic rhinitis due to

animal dander / acute viral URI / influenza, confirmed or suspected /

RSV infection / symptom only]

• Certainty: [confirmed / suspected / symptom only, diagnosis not

established]

• Coexisting conditions this visit: [ ]
• Basis: [history / exam / test result]

```

This is where coding follows the wording. The FY 2026 ICD-10-CM Official

Guidelines for outpatient services (Section IV) set the rules:

• Uncertain diagnoses aren't coded as confirmed. Section IV.H says:

"Do not code diagnoses documented as 'probable', 'suspected,'

'questionable,' 'rule out,' 'compatible with,' 'consistent with,' or

'working diagnosis'". Instead, code "to the highest degree of

certainty for that encounter/visit, such as symptoms, signs, abnormal

test results, or other reason for the visit."

• Symptoms are acceptable when the diagnosis isn't established.

Section IV.D says symptom codes are acceptable "when a diagnosis has

not been established (confirmed) by the provider."

• Coexisting conditions are coded. Section IV.J says to "Code all

documented conditions that coexist at the time of the encounter/visit

and that require or affect patient care, treatment or management." A

patient with ragweed allergic rhinitis can also have a cold.

• Influenza has its own rule. Section I.C.10.c says coding for

identified influenza "should be based on the provider's diagnostic

statement". It adds that "confirmation" does not require documentation

of positive laboratory testing specific for the identified virus. If

the provider records "suspected", "possible" or "probable" identified

influenza, a code from category J11 is assigned instead.

• Integral symptoms aren't added. Section I.B.5 says "Signs and

symptoms that are associated routinely with a disease process should

not be assigned as additional codes."

The codes these assessments usually map to (titles from the ICD-10-CM

code set via the

NLM Clinical Tables

service):

| Assessment in the note | ICD-10-CM code and title |

|---|---|

| Allergic rhinitis, pollen | J30.1 Allergic rhinitis due to pollen |

| Seasonal allergic rhinitis, other | J30.2 Other seasonal allergic rhinitis |

| Allergic rhinitis, cat or dog | J30.81 Allergic rhinitis due to animal (cat) (dog) hair and dander |

| Allergic rhinitis, other | J30.89 Other allergic rhinitis |

| Allergic rhinitis, not specified | J30.9 Allergic rhinitis, unspecified |

| Common cold | J00 Acute nasopharyngitis [common cold] |

| Viral URI, not specified | J06.9 Acute upper respiratory infection, unspecified |

| Influenza, virus identified, upper respiratory | J10.1 Influenza due to other identified influenza virus with other respiratory manifestations |

| Influenza, virus not identified | J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations |

| RSV bronchiolitis | J21.0 Acute bronchiolitis due to respiratory syncytial virus |

| RSV as the cause of another condition | B97.4 Respiratory syncytial virus as the cause of diseases classified elsewhere |

| Fever, diagnosis not established | R50.9 Fever, unspecified |

Section IV.F asks for "the highest level of specificity when supported

by the medical record documentation." That is why "allergic rhinitis

due to ragweed pollen" in the note is worth more than "allergies." The

allergy ICD-10 coding guide

has the wider allergy code set. Check every code against the current

code set and your payer's rules.

Template 5: plan and return precautions

```

PLAN

• Allergic rhinitis: [continue / change; reason]
• Viral illness: [supportive care / referred to PCP / testing]
• Asthma action plan reviewed: [yes / no / not applicable]
• Flu vaccination status discussed: [ ]
• Return precautions given: [ ]
• Follow-up: [interval]

```

CDC's list of emergency warning signs for flu in adults includes

difficulty breathing or shortness of breath, "Persistent pain or

pressure in the chest or abdomen", and "a fever or cough that improves and then returns or

worsens." If the clinician gave return precautions, the note should say

which ones. The longer rhinitis plan, including treatment changes, is

covered in the

allergic rhinitis visit note template.

Where Medora fits

Medora is an AI copilot built only for allergy and immunology practices,

built with a working allergy practice.

• Medora Copilot listens to the allergy visit and drafts an

allergy-structured SOAP note: HPI, review of systems, assessment and

plan, and workup. The draft includes pertinent negatives, for the

clinician to review.

• It has visit templates built for allergy, including new patient,

follow-up and asthma visits.

• Each assessment item in the note carries its suggested ICD-10 code for

the clinician to review. The certainty wording, and the code that

follows from it, is the clinician's.

• Evidence Mapping links lines in the review of systems and the

history back to the moment in the visit conversation where they were

said. The clinician can click a linked line and see its source before

signing.

• Patient Intelligence keeps a structured allergen profile for each

patient that builds across visits. At a follow-up it shows a snapshot

of the prior visit. Everything it shows is advisory.

• The clinician reviews, edits and signs every note. Medora doesn't

diagnose, doesn't decide between allergy and infection, and doesn't

order tests or treatment. Those stay with the clinician.

In a 60-day pilot at a working allergy practice, the time an allergist

spends signing off each skin-test visit dropped sharply

(the case study).

Frequently asked questions

How do you document allergies vs. a cold in the visit note?

Record the onset (sudden or gradual) and the number of days, whether the

same thing happened last season, and the exposure pattern. Add the

pertinent negatives, such as no fever, no body aches, no chills and no

sick contacts, and the pertinent positives, such as itching, sneezing

and the type of discharge. Then write an assessment worded to match the

clinician's certainty.

Does allergic rhinitis cause a fever?

ACAAI says hay fever does not cause a fever, while a cold may bring a

low-grade fever. CDC notes that not everyone with flu has a fever, so

"afebrile" is a useful negative but doesn't settle the question by

itself.

How should a suspected flu be coded at an allergy visit?

Under the FY 2026 ICD-10-CM guidelines, if the provider records

"suspected", "possible" or "probable" identified influenza, a code from

category J11 (influenza due to unidentified influenza virus) is assigned

rather than J09 or J10. Confirmation for J09 and J10 rests on the

provider's diagnostic statement and does not require documented positive

lab testing.

Can allergic rhinitis and a viral URI be coded at the same visit?

Yes, if both are documented. The outpatient guidelines say to code all

documented conditions that coexist at the visit and affect care,

treatment or management.

Who decides whether it is allergies or a virus when Medora drafts the note?

The clinician. Medora Copilot drafts the note, including the pertinent

negatives the patient reported, and the clinician makes the assessment,

reviews the suggested codes, and edits and signs the note.

Try Medora Scribe on your own visits

• Start the 14-day free trial of Medora Scribe (no card needed)
• See how Medora handles allergy documentation
• Book a demo
• Read the full buyer's guide
• The allergy new patient consult note template

*Sources (quotes are from these pages):

CDC, Signs and Symptoms of Flu, https://www.cdc.gov/flu/signs-symptoms/index.html;

CDC, Symptoms of RSV, https://www.cdc.gov/rsv/symptoms/index.html;

CDC, Clinical Overview of RSV, https://www.cdc.gov/rsv/hcp/clinical-overview/index.html;

CDC, Flu and People with Asthma, https://www.cdc.gov/flu/highrisk/asthma.htm;

AAAAI, Colds, Allergies and Sinusitis: How to Tell the Difference, https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/colds-allergies-sinusitis;

ACAAI, Hay Fever (Rhinitis), https://acaai.org/allergies/allergic-conditions/hay-fever/;

Weaver-Agostoni J, Kosak Z, Bartlett S. Allergic Rhinitis: Rapid Evidence Review. Am Fam Physician. 2023;107(5):466-473, https://www.aafp.org/pubs/afp/issues/2023/0500/allergic-rhinitis.html;

CMS and NCHS, ICD-10-CM Official Guidelines for Coding and Reporting FY 2026, https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf;

code titles from the NLM Clinical Tables ICD-10-CM service, https://clinicaltables.nlm.nih.gov/.

Follow your own protocols and check codes against the current code set.*